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INSTRUCT IONS
<br />EMERGENCY
<br />Leak Being Confirmed - Leak suspected at site, but has not been confirmed.
<br />Indicate whether emergency response personnel and e uipmert were involved
<br />Preliminary Site Assessment Workplan Submitted -,workplan/propossl
<br />at any time, if so, a Hazardous Material Incident Reoors- should be filed
<br />requesters of/submitted by responsible party to determine whether ground
<br />with the�State office of Emergency Sar aces 'OES) at 2800 Meaeowview Road,
<br />grater has been, ox will he, impacted as -a result of the releasa<
<br />Sacramento, CA 95832. Copies of the GES report form may be`oCtained at
<br />Preliminary Sate Assessment Underway,' implementation of workplan,
<br />your local underground storage, tart peri'd ttibg agency. Indicate whether
<br />E'ollution Characterization - responsible) party; as in the of fully
<br />the OES report has been filed as of :he date of this :report;'
<br />,process
<br />defining the extent of contamination in soil end ground crater and assessing
<br />impacts
<br />impacts or. surface and/or ground dater.
<br />LOCAL AGENCY ONLY,
<br />Flan - remediation pian submitted evaluating long term
<br />To avoid duplicate notification purse t to Health and Safety code Section
<br />remediation options, Proposal and implementation schedule for appropriate'
<br />25180.5, a government employee should sign and date the foray. in this block.
<br />remediation options also submitted.
<br />A signature here does not mean that the leak has beer, determined to pose a
<br />Cleanup Underway -'implementation-of remediation plan.
<br />significant threat to human health or iiiatety, only that notification
<br />Post Cleanuxsionitorin iso Proxress periodic ground water or other
<br />procedures have been followed if required,
<br />monitoring at site, as necessary', to verify and/or evaluate effectiveness
<br />of remedial activities.
<br />REPORTED BY
<br />Enter
<br />r
<br />Case Closed; --regional board and local agency in Concurrence that no
<br />y-ur name,telephone number, and address. Indicate which party you
<br />further work is necessary at the site,
<br />represent, and provide Company or agency name.
<br />SPC3t�S7PS E F Ti
<br />I PORT T: THE INFORMATION PROVIDED ON THIS FORMIS INTENDED FORGENERAL
<br />STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br />Enter name, telephone number, contact person, and address of the party
<br />OFFICIAL POSITIION OF ANY GO NTA; AvENCY
<br />responsible for the leak. The responsible party would normally he the tank
<br />owner.,
<br />REMEDIAL ACTION'
<br />Indicate
<br />Indicate which action have been used to cleanup or remediate the Leak.
<br />SITE LOCATION
<br />of isptions follow:
<br />Enter information regarding the facility,' At a minimum, you must
<br />provide the facility scale and full address.
<br />Cap`Site - install-horizontal impermeable layer to reduce rainfall
<br />infiltration.
<br />IMPLEMENTING AGENCIES -
<br />Containment Harrier - install vertical dike to block horizontal movement of
<br />Enter names of the local agency and Regional Water Quality, Control Hoard
<br />contaminant'.
<br />involved.
<br />Excavate anter,Tlis se - remove contaminated soil and dispose in approved
<br />site.
<br />SUBSTANCES INVOLVED
<br />Excavate and Treat - remove contaminated soil and treat (includes spreading
<br />EnteT the came aiad quantity lost of the hazardous substance involved. Room
<br />or land farming).
<br />is provided for information-on two substances if apprespriate. li sra2'e than
<br />Remmove Free Product - remove floating product from water table.
<br />two-substances leaked, list the two of most concern for cleanup.
<br />Pump and T eaf Groundwater - generally employed to remove dissolved
<br />contaminants
<br />DISC®VERYJABAT EIdT
<br />Enhanced Bi6de1iadation - use of any available technology to promote
<br />Provide information regarding the discover and abatement of the .leak,
<br />$ g j? _.
<br />bacterial d2CCiiagp6Sition of contaminants,
<br />SC CElCAUSE
<br />Replace SuvRly - provide alternative water supply to,affected parties.
<br />Treatment aL fgokup - install water treatment devices at each dwelling or
<br />Indicate source(s)' of leak. Check box(es) indicating cause-of Leak:'
<br />other place of use.
<br />Vacuum Extract - use pumps or blowers to draw air through soil..
<br />CASE TYPE
<br />Vent Soil -:bore holes in soil to,allow volatilization of contaminants.
<br />Indicate the Case type category for this leak. Check one box only. Case
<br />No Action i(eauared re incident is minor, requiring no remedial action,
<br />type is based, on the most sensitive resource affected. For`examzpie, if
<br />both soil and ground water have been affected;, case type will be 'Ground
<br />CC{ NTS - Use tbis'space to elaborate on any aspects of the incident.
<br />Water". Indicate "Drinking dater" only if one or more municipal or
<br />domestic nater wells have actually been affected. A "Ground dater"
<br />SIGNATURE - Signa the farm in the space provided.
<br />designation doesriot amply haat the affected water cannot be, or is `-trot,
<br />used fox drinking water, but only that-stater wells have rot yet been
<br />DISTRIBUTION,
<br />affected. It is understood that case t e may change upon further
<br />If the furan is completed by the to owner or his agent, retain the last copy
<br />investigation.
<br />and forward. the remaining copies intact to your local tants permitting agency
<br />for distribution.
<br />CURRENT STATUS
<br />1. (original - Local `� TAr& Permitting Agency
<br />Indicate the category which best descrekes the current status of the case.
<br />2. State Water Resources Control -Board, Division of Clean Water Programs,
<br />Check one box only. The. 'response should be relative to the case type. For
<br />Underground Storage Tank Program, F.(). Box 944212, Sacramento;; CA 44244-
<br />example, if case type is "Ground Water", "Current Stat as" should refer
<br />2120
<br />,then
<br />to the statics of the ground water investigation or cleanup, as opposed to
<br />3, Regional dater Quality Control Board
<br />that of soil.. Descriptions of options follow.-
<br />4. Local Health Officer grad County Board of Supervisors or their designee to
<br />receive Proposition 65 notifications.
<br />fto Action Taken - No action has been tacker by responsible party beyond
<br />5. Owner/responsible party.
<br />ini`_ial'report of. leek_
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